Urethral Stricture Management. AUA Guidelines. Michael Coburn, MD Scott Department of Urology Baylor College of Medicine Houston, Texas

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1 Urethral Stricture Management AUA Guidelines Michael Coburn, MD Scott Department of Urology Baylor College of Medicine Houston, Texas

2 Urethral Stricture Guidelines Systematic peer-reviewed literature review articles selected Evidence strength rating applied: A (high quality evidence, high certainty) B (moderate quality evidence, moderate certainty) C (low quality evidence, low certainty) Evidence-based statements of Strong, Moderate or Conditional Recommendations based on risks and benefits Clinical Principles, Expert Opinions

3 Urethral Stricture Guidelines Diagnosis / Initial Management (1-6) Dilation / Internal Urethrotomy / Urethroplasty (7 12) Anterior Urethral Reconstruction (13 22) Pelvic Fracture Urethral Injury (23 25) Bladder Neck Contracture / Vesicourethral Stenosis (26 28) Special Circumstances (29 31) Postoperative Follow-up (32) MOSTLY C, Expert Opinion, and Clinical Principles

4 Diagnosis and Initial Management Key Points If non-urgent intervention planned, determine length and location of stricture (cystoscopy, RUG, US urethrography) May utilize endoscopic management (dilation, DVIU)or SP tube for retention of urgent catheterization May place SP tube prior to definitive urethroplasty in patients dependent on urethral catheter or on CIC

5 Dilation / Internal Urethrotomy Urethroplasty Key Points May offer dilation, DVIU or urethroplasty for initial treatment of short (<2cm) bulbar strictures [CR, C ] May perform either dilation of DVIU as endoscopic treatment for stricture May safely remove catheter within 72 hrs after uncomplicated dilation or DVIU In patients who are not candidates for urethroplasty, may recommend self-cath after DVIU to maintain patency Should recommend urethroplasty (instead of repeated endoscopic intervention) for recurrent anterior urethral stricture if fail dilation or DVIU Refer patients for urethroplasty if lack expertise

6 Anterior Urethral Reconstruction- Key Points May initially treat meatal or fossa navicularis stricture with dilation or meatotomy Should offer urethroplasty for recurrent meatal of f.n. strictures Should offer urethroplasty for penile urethral strictures, given high recurrence rate with endoscopic management Should offer urethroplasty as initial treatment for long (>2cm) bulbar strictures, given low success rate of DVIU May offer perineal urethrostomy as long-term treatment option as alternative to urethroplasty Should use oral mucosa as first choice when using grafts for urethroplasty Should not perform tubularized grafts or use hair-bearing skin for substitution urethroplasty

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8 Buccal Mucosa Augmentation BMG pulled inside Two BMG quilted

9 Full length augmentation via perineal incision

10 Alternative to buccal mucosa split thickness skin grafts for long defects, staged

11 Pan-urethral Strictures Strictures that involve multiple areas of the urethra or the entire (anterior) urethra Etiologies include: Iatrogenic and other trauma Infectious/inflammatory disease Lichen sclerosis / BXO Goel et al. Indian J Urol 2011: 27:

12 Management options for Panurethral Stricture? - Periodic dilation / self cath - Single stage or multistage reconstruction - Perineal urethrostomy - Creation of catheterizable abdominal stoma - Permanent catheter (SP tube) - Supravesical diversion

13 Pelvic Fracture Urethral Injury Key Points Use RUG, VCUG or endoscopic assessment for preop planning of delayed urethroplasty Should perform delayed urethroplasty rather than endoscopic procedures after urethral obstruction/obliteration due to PFUI Definitive urethral reconstruction after PFUI should be pursued only after major injuries stabilize and safe positioning is appropriate

14 Delayed Posterior Urethroplasty Posterior Urethral Disruptions Expose the bulbomembranous urethra Mobilize the anterior urethra distally Transect the urethra and excise all scar Spatulate both urethral ends Perform a tension-free anastomosis Stent the repair

15 Anastomotic Repair

16 Bladder Neck Contracture / Vesicourethral Stenosis Key Points May perform dilation, bladder neck incision or TURBNC after endoscopic prostate procedures. May perform dilation, bladder neck incision or transurethral incision for post-prostatectomy VU anastomotic stricture May perform open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy VU anastomotic stenosis

17 Pre-op RUG + VCUG PFUI

18 Special Circumstances In men requiring CIC (for NGB, etc.), may offer urethroplasty for urethral strictures causing difficulty with self-catheterization May perform biopsy for suspected LS (BXO), and must perform biopsy if urethral cancer is suspected For LS (BXO) - proven stricture, should not use genital skin for reconstruction

19 Postoperative Follow-up Clinicians should monitor urethral stricture patients to identify symptomatic recurrence following dilation, DVIU or urethroplasty